A Proactive Risk Assessment Methodology to Enhance Patient Safety: Reducing Wrong Site Surgery as a Preventable Medical Error

Abstract

Patient safety has been a major area of concern over the last decades in the healthcare industry. The number of preventable medical errors in hospitals has been noticeably high. These errors are more likely to occur in intensive care units including Operating Rooms (ORs). Wrong site surgery is one of the critical sentinel events that occur in healthcare settings. This paper fills an important gap by proposing an integrated, system-oriented methodology for proactive risk assessment of operations in ORs, to specifically analyze the wrong site surgery issue, through the identification and monitoring of appropriate Leading Safety Indicators (LSIs) to evaluate the safety of those operations and generate warning/predicting signals for potential failures. These LSIs are identified across the layers of an introduced framework, which is built on the foundation of the Human-Organization-Technology (HOT) model originally developed by Meshkati (1992). This multi-layered framework captures the contributing causes of wrong site surgery.